My apologies to those who have been waiting. Someone who I see personally reminded me that I hadn’t posted anything for quite some time, and I reiterated that I first started this with the avowed intention of creating only original material, but a busy schedule is the enemy of reflection, and I have been busy.

The topic that I’m thinking of right now is hardly original– suicide, and the prevention of suicide. The intention to write more about it was galvanized into action by reading an item on the NPR website about cutting suicide risk after a hospitalization for an attempt. One of the key points in the story is that suicidal thoughts, feelings, and urges don’t last very long– anything from a few minutes to a few hours. For those who have followed this blog, you may remember my post about how the negative mood time dilation effect can make an hour seem like forever. Still, it’s endurable, and survivable. Some of the ways to get through this crisis time are skills such as those taught in DBT; self-soothing, distraction, and turning the mind.

The story also points out that what has worked is creating a safety plan with the help of a trained professional. I have done the safety plans with a number of people who were in crisis, and all of them are alive today. If you are thinking of doing the safety plan on your own without use of a professional, my suggestion is to contact a professional mental health person as soon as possible, but if you feel an urgent need to create a safety plan for yourself, then go ahead– but get the professional help.

The other thing that I have written about before which relates to this is the truth that we can be experiencing very strong negative emotions– grief being chief among them– without having a mental disorder. We can also, alas, have strong grief and other negative emotions concurrently with a mental disorder. Life doesn’t allow us to put one problem on hold while dealing with another, unfortunately. My image for this has always been that the ship of my life is at sea with a leak in the hull and a fire on deck. If I only fight the fire, the ship sinks. If I only fix the leak, the ship burns to the waterline. Sometimes there’s no getting around it. But experience shows that when we get through the crisis, life can have good things for us again on the other side– or even in the middle of the crisis.

When I think of this topic I remember a client I had who shot himself in the head– before I ever met him. By some miracle, no part of his brain was definitively damaged, and he recovered. By the time I met him, he was seeking help for other problems, and was no longer suicidal. In fact, after his attempt, he had endured trials that would have made other people become suicidal, but was not. Sometimes the light at the end of the tunnel really is daylight.

Just wanted to give that shout out to Mental Health Awareness Month before it’s over. Before looking it up, I didn’t know that it has been going on in one form or another since 1949

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This year the theme is #4mind4body and there are various things about mind/body wellness that you can find at the link. Here’s just one item from the toolkit:

Health and wellness are hot topics, but did you know a healthy lifestyle can help to prevent the onset or worsening of depression, anxiety and other mental health conditions, as well as heart disease, diabetes, obesity and other chronic health problems? It can also help people recover from these conditions. Learn about the mind-body connection with this year’s #MHM2018 fact sheets: bit.ly/MayMH

There’s also some interesting stuff about new developments in gut health and mental health. As a part-time tree-hugger, I like the idea that every person is a walking ecosystem and that care of our personal gut ecosystem can make us feel psychologically better.

For me, the great advantage to doing the physical health side of mind/body wellness has always been the concrete, tangible nature of it. If I go for a walk or eat a healthy food, I know I did it. I know I can do it again. It’s real & nobody can take that away from me. That, in itself, creates a mental boost.

Take care of yourself, and reach out to each other. This month, and every month.

…is not necessarily bad. The two best things I try to remember about anger come from the Seeking Safety book and from a training I attended some years ago on facilitating anger management groups (which tend to be mostly mandated clients with criminal justice involvement).

The first idea, from Seeking Safety, is the idea that anger is a sign of unmet needs. That makes complete sense to me. If there is something I need, and I’m not getting it, I can get angry.

The second idea, from anger management, is that anger is not a primary emotion. It is, in this view, a secondary emotion, a front for either underlying sorrow or fear. In fact, the trainer who taught the course went so far as to say that anger is never the primary emotion, and that it always is a front for sorrow or fear. Such a categorical statement piqued my interest, and especially my sense of contrariness. Is there never an exception? This was many years ago, and I’m still looking for an exception.

Here’s the basic idea about why we get angry: fear and sorrow are vulnerable emotions. Anger, and especially rage, represent a strong, even an invulnerable feeling. The ultimate version is when someone goes berserk or runs amok– two words, one from the Vikings and one from Malaysia, that represent what some translators have called “battle fury,” the extreme fight-or-flight reaction where strength greatly increases, sensitivity to pain may be greatly diminished or absent, and rational thought is on hold. When a person gets addicted to being high on their own fight/flight chemistry, this person is the classic “rageaholic.”

From some perspectives, we can see the up side of anger– if I’m truly in a life threatening situation, going berserk has survival value. We have heard the stories of the mom who lifts up a car when a jack slips, pinning her teenage son, and pulls him to safety, or the wounded soldier who runs fifty yards to safety after losing a foot. There are various true examples of how this extreme physical reaction can be life-saving. What the stories don’t include is that the mom has a bad back forever after & the wounded soldier is still in very bad shape. But lives have been saved.

But most of us are not in life or death situations when we get angry. So what’s the up side then? Well, feeling strong, feeling less vulnerable. If you hurt me and I get angry with you– even fly into a rage– now I feel strong, not vulnerable. So which do I want to feel? Strong and invulnerable, or hurt and vulnerable? It’s understandable, seen in this light, how one might choose the strong, angry feeling over the vulnerable, sad or fearful feeling.

The problem with choosing the invulnerable anger response is that when it borders on or becomes rage, rational thought is typically shut down. Perhaps I can’t stop to think that my spouse obviously didn’t mean to get in a car wreck– I just focus on the fact that the car got wrecked and my spouse was driving. I may not even stop to think if it was the other driver’s fault, or if I do my rage might be dangerously directed to that person. The anger management people suggest that when the fight-or-flight chemicals dump into my system, it will take at least half an hour for them to wash out.

Here’s where I double back, to the Seeking Safety idea that my anger is the sign of an unmet need. If I’m angry about the damage to my car, it may be due to my sudden fear that my loved one might have been injured or killed, or worries about money, or any number of perfectly valid fears. But none of those needs can be addressed with a baseball bat or shouting. If need be, I take half an hour to calm down before talking to anyone– especially the person I’m upset with. It’s always interesting to me that some people have intuitively figured out that they need to take a walk, or sit in a quiet room, or otherwise calm down before continuing to deal with an upsetting situation. It’s equally interesting (puzzling, I’ll admit) that people can get coaching on this, including the physiological reason for why it’s necessary, and still not give it a try.

The other thing about anger is that anger is a form of energy. We can think of emotions as our motivators– the driving forces of our lives. So it’s good to have energy, but it needs to be usefully directed. The rational mind is the part that channels the energy. Practically speaking, it’s better to self-monitor and respond to unmet needs (anger) when they are still manageable. This is the part where the client-therapist dialogue, or an inner dialogue with oneself, begins. How do you stay aware of your own needs, your sorrows, your fears, your anger? How do you monitor yourself? What ways do you have to meet your needs? If you feel you have an anger problem, you need to be able to answer those questions in order to successfully cope with anger and without negative outcomes. Anger management is an entire industry, but enough for now.

Are not the same. I remember a client once saying that she had broken up a longstanding relationship and her parents were worried about her becoming depressed. She was, in fact, on antidepressant medication and had been having problems. However in this case, she told them, “I’m not depressed, I’m sad.” It makes sense, doesn’t it? On the other hand, just because you’re sad doesn’t mean you’re not depressed, and vice versa.

In one of the first professional trainings that I attended as a peer counselor, the psychiatrist who was presenting on the subject of co-occurring substance use disorders and other mental disorders repeated several times, “Just because you have one problem doesn’t mean you don’t have another.” This applies just as much to the combination of grief and depression. It is potentially even more applicable because of the existence of complicated grief. A great discussion of all these can be found here.

For me, one of the key points is that grief is not typically associated with feeling like a personally flawed or failed person. Depression, however, often includes such feelings. When I grieve the loss of a loved one, one of the things that I am aware of is that the person had endearing characteristics which I recall fondly, albeit with grief for the loss. Depression rarely includes such positives. Likewise, in grief I am aware that my period of grieving is a tunnel which can have an end, whereas depression is more likely to feel endless.

One of the most memorable things from my training as a therapist was a statement about grief made by a seventy year old professor in a class about what normal humanity looks like. As an older student, I had already experienced some of the normal grief and loss of life, including my grandparents and many friends in the AIDS epidemic. Some of the younger students apparently had not, and one asked the professor, “When you lose a family member, how long does it take to get over it?” The professor answered in a heartbeat: “You don’t get over it, you get used to it.” This is a key thing about grief: we never wish to forget about the loss of a loved one, and the sadness of that loss will always be with us. But we become, in the course of normal grief, reconciled to the loss. In complicated grief, we are having difficulty, sometimes extreme difficulty, in becoming reconciled to the loss. The sadness of it overwhelms the ability to recall fondly the good things about the lost loved one. In depression, there is no positive aspect, no way of becoming reconciled with the suffering, and typically no rational reason for the suffering.

In the article for which I included a link earlier, the idea of “proper sorrows” is included. Life will always bring us sorrow and loss. For some of us, it may bring depression, either separately or together with losses. For some, sorrow and loss can segue into depression. Complications like this are some of the reasons why consultation with a therapist may be a good idea. At the same time, it behooves therapists to be very alert that we do not label normal problems of life as mental disorders.

After yet another school shooting, some conservatives are calling for better mental health care. What they really mean is that mental health providers should be on the lookout for potential shooters & should then intervene to prevent them.

Howard Finkelstein, the chief public defender in Broward County, said in an interview that Mr. Cruz’s legal team had not yet decided whether to mount an insanity defense. Prosecutors have not said whether they will seek the death penalty, but Mr. Finkelstein argued that Mr. Cruz should not be a candidate for execution, given his mental health history.

“Every red flag was there and nobody did anything,” Mr. Finkelstein said. “When we let one of our children fall off grid, when they are screaming for help in every way, do we have the right to kill them when we could have stopped it?”

Of course people with mental illness should have access to care! It is a tragedy and a travesty that the criminal justice system should be the gateway to mental health for so many. It’s tragic that Nikolas Cruz should have had the record of problems and troubles he had, but received little or no help. At the same time, however, it is completely unreasonable to expect that mental health providers should be the ones charged with ensuring public safety.

There are a lot of problems with this. The first one is exemplified in the story of a Sacramento area woman who experienced involuntary detention for ten hours even after saying she had no intention to harm herself or anyone else. This was under the existing system in California, which permits certain people in health care and law enforcement to send people to a mental hospital for up to 72 hours against their will (5150). In fact, even when someone isn’t held for three days, the system may take hours to determine that the person doesn’t need to be held.

Another problem with this is that, at least in California, mental health professionals are already required to intervene under what is known as the Tarasoff rule. The Wikipedia article gives the long version, but the short version is that therapists are required to notify authorities if someone makes a credible threat against an identifiable target. But who makes people seek out mental health care?

Well, in California there’s Laura’s Law, which can compel people to engage in mental health treatment, but for someone to qualify a local jurisdiction has to opt in, and then a person needs to have a history of either legal problems or mental health hospitalizations. In the most recent school shooting (and most of the others) the perpetrators would not have qualified.

But it gets worse. In the 2012 Aurora Colorado shooting, the perpetrator was under the care of a psychiatrist prior to the shooting, but apparently neglected to tell the psychiatrist what he was planning. To steal one of Joker’s lines from an old Batman comic, “I may be insane, but I’m not crazy!” People who have mental illnesses are at least as complex and intelligent as people who do not. They may suffer greatly, but have no urge to do anything violent– to others, or to themselves. We need to remember that gun suicides are almost double gun homicides. So mental health providers are already mandated by law to be on the lookout for violence risks, and to report them. Patients know that, and can easily choose to not disclose. I personally experienced this when a client who had declined to engage in talk therapy after being referred by his psychiatrist, who was prescribing anti-depressant medication, committed a suicide that was clearly well thought out. It’s not a good feeling for a therapist.

Laws about mental health treatment, who should get it even when they don’t want it, and what mental health providers should report, when, and to whom seem unlikely to have any effect on preventing violence by mentally ill people. Even when someone is getting treatment and on the radar, the ability to predict who really is a risk for violence doesn’t really exist, beyond the obvious fact that people who already have a history of violence are likely to go on being violent. And then there are those pesky civil rights. You can’t lock people up for Orwellian thoughtcrime. At least not yet.

But wait– it gets worse. Or at least more complicated. I wasn’t able to quickly find a reference, but there was a story about inmates in California prisons who were on suicide watch lying about their suicidality in order to be released from suicide watch– who then killed themselves. This is perhaps different from assessing threats of violence to others, or perhaps not. My experience with mental health clients who were picked up and taken to psychiatric emergency as either a danger to self or danger to others is that when they are picked up by law enforcement, many of them calm down by the time they are transported to the hospital and are not admitted. Others are admitted, perhaps overnight, and then released. The point is, people can be mentally ill, can be very upset, but then can put on a good enough front to “pass” with the people charged with holding them, even if still very ill.

One of the things that makes people more likely to disclose socially unacceptable thoughts, feelings, and impulses to a therapist is the promise of confidentiality. Chop giant holes in the confidentiality contract between therapist and client and all you do is guarantee the clients won’t disclose such thoughts, feelings, and most important– urges. In fact, one researcher estimates that Duty to Warn laws actually increase homicides. I am not mathematically sophisticated enough to argue with the analysis, but the premise is intuitively acceptable: if a patient is planning something that the therapist would stop, don’t tell the therapist.

Tarasoff reporting and other laws already create the obligation for mental health providers to look out for public safety. It would also be great if mental health care really was on a parity with other forms of health care. It would be nice, come to that, if health care of all kinds was more available to more people. But making therapists into thought police won’t help the school shooting problem.

(Apologies to readers for the quick updates– it’s very hard to proofread one’s own work, and I spotted a couple of typos. Probably didn’t spot some others.)

I have reflected on many occasions that the therapist’s job has a lot to do with helping people change. But how can a therapist promote change? I think that there are three main ways.

First– and that’s why the picture– we can change by changing how we look at things. The picture will be familiar to a lot of people as an example of two things– a young woman looking away from the viewer, showing her left ear and cheek, and an old woman looking toward the viewer’s left, with what was the young woman’s smaller chin as the older woman’s larger nose. Helping people to see things differently is sometimes called reframing in the therapy business. I like to joke that politicians are evil spin doctors, while therapists are benevolent reframers. It is true that seeing things differently can change how you feel about a situation & your prospects for the changes you want. But reframing is a hazardous undertaking: a well-meaning friend once told me, when I mentioned being down about a romantic break up, “That’s great! you got the wrong relationship out of your life to make room for the right one!” The friend was actually right, but it was the wrong time & the wrong way to say it.

One of my personal Hall of Fame reframes came spontaneously from a client who was talking about dealing with some truly horrendous life difficulties. In a tone of frustrated disgust the person said, “I wish I wasn’t so good at this!” It sums up how we so often feel about getting through life’s vicissitudes. I’m getting through, and I’m good at dealing with my situation, but I wish I didn’t have to be!

The second way of changing is the method sometimes characterized as “Act as if” or “Fake it ’til you make it.” This is the behavioral method. You ask yourself, or make a plan together with your therapist, about what your outward actions would be if you didn’t have your problem. Sometimes, when making a treatment plan with a client, I ask “What would success look like if we had video of you living your life successfully, but with no sound?” This is very appropriate for things like agoraphobia. If I’m unable to get out of the house, success looks like me being out of the house. In fact, behaviorally oriented treatment for phobias in general is one of the most successful forms of psychotherapy.

The key is to remember the behaviorist’s maxim, positive reinforcement for successive approximations of the desired behavior. If I have agoraphobia and experience panic from going out the front door, I won’t start my “act as if” change with a cross-country road trip. I will more likely start by going out the back door and standing right next to it for a minute, then maybe going ten feet into the back yard for two minutes, and so on. I actually did this with a client at one point with good results.

There are more complicated examples of the “Act as if” behavior change method, but the basic idea is that change works from the outside in when using this method. The thing that makes a therapist necessary a lot of the time is the therapist can provide feedback about what constitutes a next approximation of the desired behavior as well providing the positive reinforcement. Coping with phobias in this way frequently entails a degree of distress tolerance, which is another topic all by itself. A client may be highly self-critical about progress where the therapist can, in a wholly dispassionate way, point out that the client is, in fact, making progress. Which brings us to the third way to change.

The third way to change (for our consideration right now) is how you think about things. This includes everything that comes under the heading of cognitive therapy. Much of what we consider thinking is essentially talking to ourselves– with our without moving lips or making noise. Some might consider this to have a high degree of overlap with the first kind of change, how you look at things, and I won’t disagree, but I think the two are different enough that this is a distinct category. To illustrate the overlap, I like to think of the example of the half full glass– or is it half empty? How we label it verbally is one thing, and how we actually see it is related. But I like to say that to a person drowning, the glass is half full– of air. Or to the efficiency expert, it’s twice as big as it needs to be. To a more inquiring mind, the question might arise, half full of exactly what liquid? Maybe we have assumed it’s water when it is, in fact, glycerin, another clear liquid. So how we think about things does overlap with how we see them.

But how we think about things includes, most importantly to my way of thinking, the way we think about things not seen. So to return to our hypothetical agoraphobia case. Maybe the person has trouble going out because of a fear that the neighbor will be looking out the window and holding a grenade launcher, ready to attack. This may be a firmly held (false) belief– a delusion. Working with delusions and hallucinations is outside the scope of what I’m talking about for now. But the person who is in fear may recognize that the fear of the heavily armed neighbor is irrational and highly unlikely, but still have the fear. It’s possible to change this by fact-checking oneself. One could, for example, call up the neighbor and ask, do you own a grenade launcher? The example is deliberately silly, but the basic idea remains. A closer look at many forms of anxiety suggest that we are making up a story about the future– an overly worried story. A person with social anxiety is making up a story in which he or she is the focus of disapproval by all the people in a public place. Panic disorder may arise from having fear of the consequences of a panic attack in an inconvenient place/time– even when an objective examination of a person’s history may show that panic attacks, while extremely unpleasant, haven’t stopped the sufferer from getting through life. In this case, the story one tells oneself about the attacks can create more problems than the attacks themselves.

Different therapist have labeled this process differently in the past. Albert Ellis combated irrational beliefs in his Rational Emotive Behavior Therapy, And Aaron Beck it is the name most associated with CBT, cognitive behavior therapy, which helps people identify cognitive distortions and combat them. I have a point of difference with these approaches in that I feel they put up a significant barrier to change. If I am a client and a therapist tells me my thinking is irrational or distorted, that doesn’t help me feel much better. I know I’ve got problems, which is why I’m in therapy. Don’t tell me I’m bad when I already feel bad! (For more, see Beck or for a more reader-friendly version, Burns.) Believing one is worthless because of feeling worthless in an example of the cognitive distortion known as emotional reasoning.

So how do we use these tools without the tools themselves hurting? Here’s my proposed approach: we see ourselves as creative story tellers. Let me explain. A person takes something from real life– a painful failure, for example. I’m attracted to someone and hope that they may be attracted to me, so I ask them out.They decline my offer. I feel hurt and disappointed. Now I make up a story, and it goes like this: “I always get rejected, I’ll never have a lover.” It’s a short story, and a tragic one. But it’s made up. When I start fact-checking myself, things may be different. Maybe I had a lover in the past, which proves that my statement about never having a lover is false. Likewise, if I had a past relationship it demonstrates that the word always is too extreme. This is a way of identifying the thinking problem that is labeled “all-or-nothing” or “black and white” thinking. I still may have relationship problems. Maybe I pick inappropriate candidates as potential partners. Maybe my relationship failed because of something I did, or through no fault of my own– the other person might have their failures & shortcomings, too. But all/nothing doesn’t help me identify a path to success.

So here’s my reframe of CBT itself: we are all creative story tellers, even myth makers. It comes to us so naturally that we don’t even realize we are doing it. We make up stories and we fall in love with our stories. We even come to believe our stories. But sometimes our stories aren’t helpful; they can even be hurtful. We can mitigate the negative effects by fact-checking our own stories as dispassionate journalists, or scientific researchers might.

In the example above, there is still the pain of rejection by the hoped-for partner. This process doesn’t solve all problems, it’s just a tool. Solving problems requires other things– patience, practice, careful observation, diligence. But it is a great place to start.

For example, I just used the word partner in the rejection example. That suggests that I already made up a story about asking someone out, them accepting, us getting along, getting along even better, my attraction being reciprocated, and a relationship developing. Stories pervade our lives so deeply that it takes thoughtfulness to spot them, and a single word can reveal a rather detailed story.

The point that I want to emphasize is that there’s nothing inherently wrong or bad about the story. Another example– the famous statement, “For your dreams to come true, first you must dream.” Most of us dream of having fulfilling intimate relationships. In my value system, this is a good thing. There are boatloads of studies showing that good relationships support better physical health, much less mental health. We can have personal stories, small or large, that are hopeful, helpful stories.

This comes back to the interplay between how & what we think, how we see things, and how we behave. There are clearly complex interactions among the three possible avenues to change. But the good news is that it’s possible to start anywhere. At least that’s the story I’m using, because when I act as if it’s true, I can see things differently.

The image is widely available but this copy was taken from http://www.grand-illusions.com/opticalillusions/woman/

Sorry to have been MIA for so long. As some who follow the blog may remember, I am trying to keep my promise to focus on original content, but this news item on bipolar depression looked too significant to pass up, especially with the winter upon us. I will try to get a new post out soon.